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Cognitive-Behavioral Techniques With the Compliments of Springer Publishing Company, LLC JOURNAL OF COGNITIVE PSYCHOTHER APY www.springerpub.com/jcp Journal of Cognitive Psychotherapy: An International Quarterly Journal of Cognitive Psychotherapy: An International Quarterly Volume 25, Number 4 • 2011 25 4 2011 CBT-IA: The First Treatment Model for Internet Addiction Kimberly S. Young, PhD Center for Internet Addiction Recovery, Bradford, Pennsylvania Research has identified Internet addiction as a new clinical disorder that causes relational, occupational, and social problems. Cognitive behavioral therapy (CBT) has been suggested as the treatment of choice for Internet addiction, and addiction recovery in general has used CBT as part of treatment planning. This article outlines cognitive behavioral therapy–Internet addiction (CBT-IA), a uniquely designed model for treating Internet addiction applying CBT with harm reduction therapy (HRT). CBT-IA uses a three-phase approach. In the first phase, behavior modification is used to gradually decrease the amount of time the addict spends online. In the second phase, cognitive therapy is used to address denial that is often present among Internet addicts and to combat the rationalizations that justify excessive online use. The third phase applies HRT to identify and treat coexisting issues involved in the development of compulsive Internet use. As the first model of its kind, it can be used both on an outpatient and inpatient basis to deal with this emergent client population. Keywords: cognitive behavioral therapy; Internet addiction; recovery; treatment; harm reduction therapy tudies on Internet addiction originated in the United States. More recently, studies have documented Internet addiction in a growing number of countries such as Italy (Ferraro, SCaci, D’Amico, & Di Blasi, 2007), Pakistan (Suhail & Bargees, 2006), and the Czech Republic (Simkova & Cincera, 2004). Reports also indicate that Internet addiction has become a serious public health concern in China (BBC News, 2005), Korea (Hur, 2006), and Taiwan (Lee, 2007). About 10% of China’s more than 30 million Internet gamers were said to be addicted. To battle what has been called an epidemic by some reports, Chinese authorities regularly shut down Internet cafes, many illegally operated, in crackdowns that also include huge fines for their operators. The Chinese government has also instituted laws to shut down the number of hours adolescents can play online games and opened the first inpatient treatment center for Internet addiction in Beijing. In the United States, Internet addiction has also been consid- ered for classification in the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-V; Block, 2008), and it is expected to be included in the appendix for the upcoming edition. It is difficult to estimate how widespread the problem is. Given the popularity of the Internet, detecting and diagnosing Internet addiction is often difficult as its legitimate business and per- sonal use mask addictive behavior (Young, 2010). However, in a nationwide study conducted by a team from Stanford University’s School of Medicine, it was estimated that nearly one in eight © 2011 Springer Publishing Company 10.1891/0889-8391.25.4 304 © 2011 Springer Publishing Company http://dx.doi.org/10.1891/0889-8391.25.4.304 Copyright © Springer Publishing Company, LLC CBT-IA: Treating Internet Addiction 305 Americans exhibit at least one possible sign of problematic Internet use (Aboujaoude, Koran, Gamel, Large, & Serpe, 2006). Researchers have likened Internet addiction to impulse-control disorders on Axis I in DSM-IV (e.g., Aboujaoude et al., 2006; Beard & Wolf, 2001; Block, 2008; Shapira et al., 2003; Young, 1998) and have used various forms of DSM-IV based criteria to define Internet addiction. Cognitive behavioral therapy (CBT) has been shown to be an effective treatment for impulse con- trol disorders such as intermittent explosive disorder, pathological gambling, and trichotillomania (Hucker, 2004). CBT has also been effective in treating substance abuse, emotional disorders, and eating disorders (Beck, 1979; Beck, Wright, Newman, & Liese, 1993). Researchers have suggested using CBT to treat Internet addiction (e.g., Greenfield, 1999; Hansen, 2002; Orzack, 1999), given the compulsive nature and similarity to other disorders successfully treated with CBT. However, Internet addiction has been noted to be different from other compulsive syndromes given the daily and necessary use of the Internet and technology in general. Therefore, this article outlines cognitive behavioral therapy–Internet addiction (CBT-IA), a uniquely designed model for treat- ing Internet addiction, applying CBT with harm reduction therapy (HRT). As the first model of its kind, this article explores how CBT-IA can be applied to reduce symptoms, improve impulse control, challenge cognitive distortions, and address personal and situational factors specifically associated with compulsive use of the Internet. WHY USE COGNITIVE BEHAVIORAL THERAPY ? CBT is a familiar treatment based on the premise that thoughts determine feelings. In general, clients are taught to monitor their thoughts and identify those that trigger addictive feelings and actions while learning new coping skills and ways to prevent a relapse. CBT usually requires 3 months of treatment or approximately 12 weekly sessions. With Internet addicts, it has been suggested that the early stage of therapy should be behavioral, focusing on specific behaviors and situations where the impulse control disorder causes the greatest difficulty (Hall & Parsons, 2001). As therapy progresses, the focus is more on the cognitive assumptions and distortions that have developed and the effects of these on behavior (Young, 2007). When applied, techniques in- volve the assessment of the type of distortion, problem-solving skills and coping strategies train- ing, modeling in therapy, support groups, and thought monitoring. In cases of Internet addiction, abstinence recovery models are not practical because com- puters have become such a salient part of our daily lives. Clinicians have generally agreed that moderated and controlled use of the Internet is most appropriate to treat the problem. Behavior therapy should examine both computer behavior and noncomputer behavior (Hall & Parsons, 2001). Computer behavior deals with actual online usage, with a primary goal of abstinence from problematic applications while retaining controlled use of the computer for legitimate purposes (Young, 2007). For example, a lawyer addicted to Internet pornography would need to learn to abstain from adult Web sites while still being able to access the Internet to conduct legal research and to e-mail clients. Noncomputer behavior focuses on helping clients develop positive lifestyle changes for life without the Internet. Life activities that do not involve the computer are evaluated and may include activities associated with social or occupational functioning. Young (2004) found that online addicts felt a sense of displacement when online and were unable to manage central aspects of their lives because of their growing preoccupation with online use. They started to miss important deadlines at work, spent less time with their family, and slowly withdrew from their normal routines. They neglected social connections with their friends, coworkers, and with their communities, and, ultimately, their lives became unmanage- able because of the Internet. As the addiction grew, online addicts become consumed with their Internet activities—preferring online games, chatting with online friends, or gambling over the Copyright © Springer Publishing Company, LLC 306 Young Internet—ignoring family and friends in exchange for solitary time in front of the computer (Leung, 2007). Therefore, managing their time online is an initial goal of behavior therapy. Cognitive therapy is also used to deal with maladaptive thoughts often associated with addic- tive or compulsive behavior. Addictions accomplish something for the person however illusory or momentary these benefits may actually be (Twerski, 1990). Because of the pleasure that people find in their addictions, they begin to behave more intensely about them. For example, an alco- holic is often driven to drink at moments of excessive stress, or an overeater is often driven to binge on food during moments of tension. In each case, the compulsive behavior serves to reduce the underlying emotional tension and serves as a reward for future behavior. In a similar fashion, researchers suggest that Internet addicts turn to the computer to find relief from moments of painful states of mental tension and agitation present in their lives (Greenfield, 1999). Greenfield conducted an early survey of Internet users in conjunction with ABCNews.com and found more than 29% of those who were classified as addicted users reported using the Internet to “alter their mood or escape on a regular basis.” In such instances, he found that their use of the computer was less about using it as a tool and more about finding a psychological escape to cope with life’s prob- lems. Because the Internet served a useful purpose for those considered addicted, they become increasingly dependent and attached to Internet usage. Beyond using the Internet as a psychological escape, subsequent studies hypothesized that other maladaptive cognitions such as overgeneralizing or catastrophizing, negative core beliefs, and cognitive distortions also contribute to compulsive use
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